Shoulder, Elbow, Hand & Wrist Flashcards
what are the four articulations of the shoulder?
sternoclavicular joint
scapulothoracic articulation
acromioclavicular joint
glenohumeral joint
what are the capsule, ligaments, cartilage, and bone associated with the sternoclavicular joint?
Capsule, ligaments: sternoclavicular ligaments
Cartilage: hyaline, articular disc
Bone: clavicle, sternum
what are the capsule, ligaments, cartilage, and bone associated with the acromioclavicular joint?
Capsule, ligaments: AC ligaments, CC ligaments
Cartilage: hyaline, meniscus
Bone: clavicle, scapula
what are the muscle, tendon, bursa, capsule and ligaments, cartilage, and bone associated with the glenohumeral joint?
Muscle, tendon, bursa:
o Superficial: deltoid, pec, trap
o Deep: rotator cuff, long head biceps
o Subacromial space
Capsule, ligaments: capsule, GH ligaments
Cartilage: hyaline, labrum
Bone: humerus, scapula
what are the muscles and bone associated with the scapulothoracic articulation?
Muscles, tendons, bursa: trapezius, serratus, rhomboids, levator, assorted bursas
Bone: scapula, ribs
(no cartilage and ligaments bc not a synovial joint)
patterns of disease for instability
mostly young/active people
not much pain
stiffness less common
apprehension
patterns of disease for rotator cuff syndrome
middle age/older
pain with reaching and at night
stiffness less common
weakness when loss of tendon attachment
patterns of disease for fractures
young/active, and elderly/frail
acute and constant pain
stiffness is potential sequela
less common weakness
describe clavicle fractures
MOA: direct blow or FOOSH
features: rarely open, rarely NV compromise, can have thoracic cage injury
describe Tx for clavicle fractures
all: sling, RICE initially
non op: if closed, shorted <2cm, medically infirm, not wanting surgery
op: open, severe shortening/displacement, combined injuries, pt preference, painful non-unions
describe AC joint separation
MOA: direct blow to shoulder (contact sports)
AC ligaments injured, CC ligaments injured
Rockwood classification of ligament injuries
describe Tx for AC joint separation
AC: sling, rice, PT
CC & AC: sling, periscapular muscle rehab, reconstruct torn ligaments for heavy labourers
describe GH joint dislocation
common, shoulder dislocation, reduction, can become recurrent
describe anterior GH joint dislocation
MOA: arm outstretched, force applied
most common type
shoulder looks squared, NV exam needed
need emergency reduction
what is bankart dislocation
avulsion (tearing) of anterior (inferior) labrum (cup-shaped cartilage that reinforces the shoulder joint)
what is Hill-Sachs
impaction of post-humerus on anterior glenoid
what is bony bankart?
rim fracture of ant-inf glenoid
describe posterior dislocation
arms flexed, adducted, internal rotation (seizures, football, electrocution)
same possible dislocations as anterior but with ‘reverse’
associated with humeral head fracture
what are static stabilizers of shoulders
bony shapes, concavity, joint capsule, labrum, glenohumeral ligaments, inherent negative pressure
what are dynamic stabilizers of the shoulder
rotator cuff muscles, long head of the biceps tendon, scapulothoracic motion, and other shoulder girdle muscles such as the pectoralis major, latissimus dorsi, and serratus anterior
how to radiologically distinguish ant vs post dislocation of shoulder
humerus is dislocated in same direction as coracoid: ant dislocation
humerus displaced away from coracoid: post dislocation
what is the mercedes benz sign?
3 points at acromion, coracoid, sacular body
if head of humerus is at center, normal
which of the following is not a synovial joint?
- Glenohumeral joint
- Sternoclavicular joint
- Scapulothoracic joint
- Acromioclavicular joint
Scapulothoracic joint
Which of the following muscles do not help operate the scapulothoracic joint?
- Serratus anterior
- Infraspinatus
- Trapezius
- Levator scapulae
- Rhomboids
Infraspinatus
Select the best pairing of diagnostic features
- Adhesive capsulitis and apprehension
- Glenohumeral arthritis and young/active person
- Seizure disorder and anterior glenohumeral dislocation
- Elderly and acromioclavicular joint separation
Seizure disorder and anterior glenohumeral dislocation
What is true about AC joint separations
- Result from a direct blow to the AC joint
- Often require ligament repair
- Can lead to AC arthritis in future
- Options 1 and 3
Options 1 and 3
what makes up the rotator cuff?
4 tendons arising from scapula infraspinatous supraspinatous subscapularis teres minor keeps humerus on glenoid, resist upward pull of deltoid
suprascapular nerve innervates
infra/supra spinatus
upper/lower subscapular nerves innervate the
subscapularis
axillary nerve innervates
teres minor
what is the most common rotator cuff tear
supraspinatous
describe the continuum of tendinopathy
bursitis –> partial thickness tear –> full thickness tear –> arthropathy
describe pathophysiology of AC joint arthritis
degenerative OA, post-traumatic arthritis
presenting complaint of AC joint arthritis?
pain on ant-lat shoulder, focal > diffuse
physical findings of AC joint arthritis?
tenderness over ACJ, pain with adduction, prominent joint
radiography of AC joint arthritis?
degenerative changes on XR
Tx of AC joint arthritis?
Rest, ice/heat, activity mod, OTC meds Topicals, NSAIDs, exercise Corticosteroid Rx (injection of joint) Surgery and chronic management
pathophysiology of long head of biceps (LHB) tendinopathy
Degeneration of tendon in bicipital groove
presenting complaint of LHB tendinopathy
ant shoulder pain, pain w resisted biceps activity
physical findings of LHB tendinopathy
Tender over LHB, pain w resisted flexion/supination
radiographs of LHB tendinopathy
thickening, tearing, fluids in tendon sheath on US/MRI
rupture does not require surgery
size of tear and symptoms do not correlate
pathohysiology of rotator cuff tears
degeneration of rendon related to vascularity, repeat use, chronic injury
presenting complaint of rotator cuff tears
pain w overhead reach, pain at night, weakness overhead
physical findings of rotator cuff tears
discomfort w strength test and impingement
AROM
radiographs of rotator cuff tears
x-ray: normal or rounding/sclerosis of greater tuberosity, prox migration of humeral head
US: good for full thickness SS, IS tears, not for partial or SSc tears
MRI not routinely required
Tx for rotator cuff tears
stepwise Tx plan, subacromial injection in bursa, surgical repair, supervised active rehab
what is scapular dyskinesis?
abnormal movement of the scapula movement
what is the region in cervical spine most associated with shoulder diseases?
C5-6
MOA of corticosteroids
inhibit prostaglandins and leukotienes, reduce inflammation/pain
advantages and pitfalls for corticosteroid use
prognostic/diagnostic use
can lead to hyperglycemia in diabetics, using it without rehab is useless
long-head bicep ruptures does not/do require surgery
does not
T/F: size of tear and symptoms are correlated
F
describe the elbow joint
3 articulations in same capsule and synovial fluid space, hinge joint
radial notch of ulna + radial head (proximal radioulnar)
trochlea + radius (humeroradial)
trochlea + ulna (humeroulnar)
describe humeral shaft fracture
fracture anywhere along the shaft of the humerus
not common
FOOSH
close to radial nerve
describe deficiency in radial nerve
wrist drop, inability to extend fingers, numbness along forearm
supplies triceps, extensor in forearm
Tx for humeral shaft fracture
straight cast, plate and screws
describe distal humerus fracture
not common unless elderly (osteoporosis)
FOOSH, sometimes open
close to ulna
describe deficiency in ulnar nerve
supplies hand intrinsic muscles, some flexors, 1.5 digits
describe Tx for distal humerus fracture
always surgery, sometimes elbow replacement
describe radial head fractures
common, more F than M
FOOSH, direct axial load or rotation force
Tx for radial head fractures
wrist exam and radiograph
sling & icepack, sometimes screw, sometimes replacement
DONT IMMOBILIZE; stiff elbows are hard to deal with
describe olecranon fractures
can be common
direct blow to elbow or FOOSH
can be open
range from simple –> smashed
static stabilizers of the elbow
ulnohumeral joint (coronoid) medial (ulnar) collateral ligament (MCL) lateral collateral ligament complex (LCL) radiocapitellar joint surgical reconstruction
dynamic stabilizers of elbow
anconeus brachialis triceps biceps active focused rehab
pathophysiology of elbow dislocations
posteolateral most common
axial loading
supination/external rotation
valgus posteolateral force
what is the terrible triad?
radial head fracture, coronoid fracture, ulnar collateral ligament injury
Tx for elbow dislocations
non-op: closed reduction, splinting @ 90 degrees
op: LCL, MCL repair
fix ulnar, radial should resolve
describe pathophysiology of distal biceps rupture
excessive eccentric tension as the arm is forced from a flexed to an extended position
symptoms of distal biceps rupture
palpable defect, muscle rolled up
Epicondylitis is defined as
inflammation of epicondyle
lateral is tennis elbow
medial is golfer’s
pain and inflammation around elbow
pathophysiology of epicondylitis
repetitive micro-trauma leading to changes in collagen and vascularity and finally structural incompetence
clinical features of lateral (tennis elbow)
pain with passive flexion and resisted extension
clinical features of medial (golfer’s elbow)
pain with passive extension and resisted flexion
Select the best combination of named bony bits and where to find them
Olecranon and proximal humerus Coracoid and anterior scapula Medial epicondyle and proximal ulna Sternoclavicular joint and distal clavicle Coronoid and anterior scapula
Coracoid and anterior scapula
Which of the following is true about rotator cuff problems?
Physiotherapy is unlikely to produce satisfactory symptom resolution
The size of the tear is predictable by symptoms
You should get an MRI to try to get them in to the surgeon faster
There is commonly no clear injury that triggers symptoms
There is commonly no clear injury that triggers symptoms
Which of the following is not a static stabilizer of the elbow joint?
Bony shape of the ulnohumeral joint Biceps Lateral ulnar collateral ligament Medial collateral ligament Joint capsule
Biceps
Choose the best combination of clinical features
Lateral epicondylitis and pain with resisted wrist extension
Medial epicondyltitis and pain with resisted wrist extension
Olecranon fracture and radial nerve injury
Distal humerus fracture and non-operative treatment
Lateral epicondylitis and pain with resisted wrist extension
describe carpal tunnel syndrome
compression of median nerve due to increased pressure in carpal tunnel
presentation of carpal tunnel syndrome
nocturnal pain, numbness/tingling, in thumb and index and long fingers, symptoms get better with shaking out hands, thenar wasting
investigations for carpal tunnel syndrome
tinel’s sign
phalen’s
reverse phalen’s
durkan’s
Tx of carpal tunnel
non-op: night time splinting, corticosteroid injections
op: carpal tunnel release
describe flexor tenosynovitis
acute bacterial infection in the flexor tendon sheath
investigations for flexor tenosynovitis? 4 things for Kanavals signs
fusiform swelling, pain with palpation, flexed posture, pain with passive stretch
Tx for flexor tenosynovitis
surgery to remove pus + ABx + irrigation
high incidence of post op stiffness
aggressive rehab after surgery
describe scaphoid fracture
largest carpal bone, 80% surface is articular
FOOSH
force to wrist in hyperextension (>90 degrees)
what does the scaphoid articulate with
Articulates w radius, lunate, capitate, trapezoid, trapezium
presentation of scaphoid fracture
wrist swelling, pain in snuff box, pain with ulnar deviation
complications of scaphoid fracture
avascular necrosis and non-union (retrograde blood supply)
can lead to SNAC (scaphoid nonunion advanced collapse)
investigation for scaphoid fracture
not always on XR, bone scan or CT compression test (push 1st MC into scaphoid)
Tx for scaphoid fracture
splint, CT if abnormal, surgery if displaced
smaller piece = higher chance of not healing
higher risk if delay in Tx
describe ulnar nerve compression
compression of ulnar nerve @ elbow
cubital tunnel at elbow close to medial epicondyle
presentation of ulnar nerve compression
numbness in D4, D5 - worse with elbow flexion
hypothenar and interosseous wasting
weakness in muscles innervated by ulnar nerve
investigation for ulnar nerve compression
Froment sign
Wartenburg sign
Duschenne’s sign
Tx for ulnar nerve compression
non-op: splint at night (straight), activity modification (avoid leaning on flexed elbow)
op: decompression, transposition
describe ulnar collateral ligament injury (skier’s thumb)
tear of ulnar collateral ligament hyperflexibility, laxity in thumb need US to visualize non-surgical for partial tears, splinting/immobilization surgical for full tear
describe Dupuytren’s contracture
nodules in palm, progress to hard cords, thickening in palm, finger doesn’t straighten all the way (D4&5 affected most)
genetic, European descent
describe mallet finger
injury to the extensor digitorum tendon at DIP cannot extend DIP, pain, numbness blunt force (ball) splint for Tx
what is high ankle sprain
MOI: external rotation and dorsiflexion
anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) torn, inferior tib-fib also torn
TX for sprains
NSAID
protective bracing
PT
surgical reconstruction for high grade
define plantar fasciitis
inflammation of thick connective tissue that support arch of foot
focal pain, morning pain/stiffness
